The smell of burning sagebrush, sweetgrass and cedar perfumes the air. A drum keeps time softly as voices quaver in song and prayer. A traditional American Indian smudging ceremony is in progress at Deaconess Billings Clinic (DBC) in Billings, Montana–a routine procedure per clinic policy, thanks to DBC’s Native American Patient Advocate, Lanette Perkins, BSN, RN.

For many Native peoples of Montana, Wyoming and the Dakotas, the mingling of smoke, breath and prayer in a smudging ceremony is believed to create more integrated spiritual and physical health or a more peaceful transition to death. “It gives them a chance to express their religious beliefs and center themselves for hope,” Perkins explains.

Many hospitals are reluctant to allow ceremonial smudging at their facilities, citing fire safety and other concerns. But the Native American Patient Advocate Program at DBC is demonstrating how, with thoughtful planning and a little extra effort, modern medicine can make room for traditional healing practices and cultural beliefs.

The smudging policy that Perkins developed for the clinic is “worded so that it’s not locked into just one culture,” she says. “At this time it might benefit one group of people, and one culture might be utilizing the policy, but it’s not exclusive to [Native American] culture.” Certain Asian cultures also perform similar ceremonies, Perkins explains. She has filled requests for copies of the policy from other hospitals, colleges and even an Aboriginal group in Ottawa, Canada.

It’s a Family Affair

Billings stands on the banks of the Yellowstone River, surrounded by forests, mountains and the Crow Indian Reservation. Deaconess Billings Clinic, which is the largest health care facility in the region, serves not only the usual mix of townspeople, ranchers and tourists but also Hutterites [a religious group whose beliefs are similar to the Amish] and Native people representing more than 40 different tribes.

Determined to serve all patients effectively, DBC received grant funding from the Rocky Mountain Technology Foundation to establish the Native American Patient Advocate Program, believed to be the first of its kind in the United States. Perkins was hired to implement the program and has been on the job for three years now. She works with patients, their families, hospital staff and tribal leaders to eliminate cultural barriers that could affect the quality of care Indian patients receive.

“When I go into a room [to meet with patients and family], I hope I can be helpful,” Perkins says. “The first thing they want to know is, who’s your mother–or in my case, who’s your dad. My dad is Crow and my mother was German, and I also have Chippewa and Cherokee ancestry. [The nursing profession frowns on nurses discussing their personal lives with patients], but there are no big secrets in my family and this the only way I can get my patients to trust me and start to work with me. The trust part is the biggest issue.”

Establishing that trust starts with introducing yourself, she continues. “I usually go around the room and introduce myself [to everyone], and they will usually tell me their name and how they are related. Some of them like a light handshake–not a heavy handshake, which may seem like a sign of aggression, but a light handshake.”

In North Plains tribes, according to Perkins, “anyone in your generation could be considered your brother or sister, even if they may actually be a very distant cousin.” Similarly, anyone in the parents’ generation may be considered a father or mother, and so on. Most hospitals are not used to accommodating such large extended family groups, but for Perkins it’s another vital function of her job as patient advocate.

For each patient, she says, “I find the family spokesperson, usually a lady about my age, because most Montana tribes are matriarchal. I talk with her and find out who is in the family and make a list. This helps the clinic staff recognize who is family to be contacted in case there is an emergency, and who will be visiting the patient. I also sort out who are the biological parents, siblings and spouse, because when it comes time for health care decisions, we need to make sure that we speak with what would be recognized in Western culture as the core family.”

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Mediating and Educating

Perkins estimates that about 60% of the staff at Deaconess Billings Clinic like the way her program seeks to adapt hospital routines to meet the cultural needs of Native American patients, but about 40% see her as an obstacle that makes it harder to do their jobs.

“I tell them, I’m not the ‘Indian Police,’” she says with a chuckle. More seriously, she adds, “I tell them, if you see me walk into your area, don’t get nervous. If I ask to have you reassigned to another patient [because of problems in establishing an effective relationship with an Indian patient], don’t think of it as a negative. Think of it as a positive: Something’s not working out well and we have to make a change [in order to provide the best possible care for that patient].”

Indeed, some of her nurse colleagues are more than willing to ask Perkins to intervene when such problems occur. “They’ll call me if there’s something that’s not going right,” she explains. “They’ll say, ‘Lanette, can you come up and see what you can do to help?’ And if there are people [who may feel threatened by] what I do, that’s an issue that they’ll have to get past.”

In addition to acting as a mediator and resolving cultural misunderstandings that may arise between Indian patients, families and staff, Perkins’ job functions also include providing cultural competency training for clinic staff. “Every two weeks, I do a portion of our new staff orientation program and we talk about culture,” she says. “[I explain that] culture can be nurses to nurses, department to department, and then we get into the [ethnic cultural differences]. We talk about respect, listening and communication. I use the University of Minnesota video ‘Getting to the Heart of It: Bridging Culture & Health Care’ to get the staff thinking about their communication style.”

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Many experts agree that communicating with respect is an essential element of cultural competence. “[In a busy health care setting,] we get wrapped up in what we’re doing, we get into a hurry and forget to take time to be respectful,” Perkins observes. But she emphasizes that “it doesn’t matter whether it’s a patient or a co-worker, we need to be respectful.”

While her official title is Native American Patient Advocate, Perkins says she’s available to advocate for anyone who needs cultural assistance. “For example, we had an Aboriginal lady from Australia in our mental health facility,” she recalls. “They had her there for three or four days and couldn’t figure out [how to communicate] with her, so they decided, ‘Why don’t we call Lanette and see if she can help?’

“I went over and just did the listening strategy. I asked questions, letting her be the teacher. It was one of my most interesting and rewarding experiences, because I learned a lot about Aboriginals. We found out what the patient’s issues were and we were able to discharge her in three or four more days.”

A Personal Cultural Journey

Recognizing that historically the North Plains tribes were often at war with each other, Perkins invests time and energy in developing relationships with various tribal leaders. She visits reservations and last year she organized a multi-tribal conference at the clinic. “If I’ve had personal, face-to-face interactions with people, the next time I call them on the phone it goes a hundred times better,” she observes. “I never take those relationships for granted. I feel blessed when I go and talk with the tribal leaders and we work together as a team.”

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Perkins’ nursing career reflects aspects of her own heritage that are meaningful to her. “My German grandmother was a teacher,” she remembers, “and my Indian grandmother was a certified nurse’s aide. She kept talking to me about nursing. In high school I worked as a nurse’s aide and I wanted to be a nurse.”

She enrolled in Montana State University, but her Indian scholarship was revoked on a technicality. She worked two jobs to pay her own way but was able to struggle through only five quarters of college. Though she never completely gave up on her dream of becoming a nurse, she did have to put it on hold for a while.

“I started my family and for 12 years I had a courier business,” Perkins says. “Mine was the only woman-owned, minority-owned transportation business in the state of Montana. I had contracts with the city, the county, Montana Power. I learned about business, customer service, how to write contracts and how to do a lot of things under state and federal regulations.

“Then, unfortunately, my husband became disabled and couldn’t work, so I had the opportunity to go back to school on scholarship,” she continues. “I went to Salish Kootenai College in Pablo, Montana, and got my ADN. But partway though I realized that for some of the things I wanted to do as a nurse, I should at least have my bachelor’s. So I took extra classes as part of my ADN program. I graduated in May, took my state boards in July and in August started the bachelor’s program at Missoula. I got my BSN in three more semesters. I didn’t want to move my family again, so I stayed in Missoula and worked for the Indian Health Service till my son graduated from high school.”

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In many respects, Perkins’ current role of patient advocate is a logical progression in her personal cultural journey. She admits that “I took a chance when I came to Deaconess, because they didn’t have the program all developed,” but she’s glad about how everything has worked out. “For me it has been a real opportunity to learn and to build,” she says.

In addition to her work at the clinic, Perkins mentors students in the Caring for Our Own Project (CO-OP) at the Montana State University College of Nursing. This nationally recognized program is designed to increase Native Americans’ access to culturally competent health care by recruiting, retaining and graduating Native nursing students.

Perkins also serves on the board of directors of the National Alaska Native American Indian Nurses Association (NANAINA). She values the opportunity of getting to know other Indian nurses through NANAINA and hearing their success stories.

As for where her own story will eventually lead, Perkins speculates that “one of these days, I’ll go back to school and get my master’s in nursing education. I want to teach. One of my grandmothers was a teacher and one was a nurse, so I’d be combining both of their vocations. Both are important components of me.”

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